Provider Demographics
NPI:1679022651
Name:PHOENIX HEALTHCARE, LLC
Entity Type:Organization
Organization Name:PHOENIX HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMIKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-669-3171
Mailing Address - Street 1:61 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-5929
Mailing Address - Country:US
Mailing Address - Phone:617-669-3171
Mailing Address - Fax:
Practice Address - Street 1:61 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-5929
Practice Address - Country:US
Practice Address - Phone:617-669-3171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-01
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216727207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty